Name: Pt. Encounter Number: Date: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness. Medications: (List with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later. Skin Skin ...

1. Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in
quotes”
HPI:
Describe the course of the patient’s illness, including when it
began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors,
pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic
testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:

2. Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic
ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or
psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or
psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney
disease?
Social History
Education level, occupational history, current living
situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,

3. and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,

4. hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal

5. Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and
oriented; answers questions appropriately.

6. Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or
lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair
evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent.
Bilateral TMs pearly gray with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa
pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules.
Oral mucosa, pink and moist. Pharynx is nonerythematous and
without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks,
rubs, or murmurs. Capillary refills two
seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs
clear to auscultation bilaterally.
Gastrointestinal

7. Abdomen obese; BS active in all the four quadrants. Abdomen
soft, nontender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no
dimpling, wrinkling, or discoloration of the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia
reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation.
No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well
rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended
bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no
hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures,
bleeding, or masses—Males: Prostrate is
smooth, nontender, and free from nodules, is of normal size,
and sphincter tone is firm).
Musculoskeletal

8. Full ROM seen in all four extremities as the patient moved
about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait
normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat.
Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions
appropriately.
Lab Tests
Urinalysis—pending
Urine culture—pending
Wet prep—pending
Special Tests
Diagnosis
o Include at least three differential diagnosis
o Final diagnosis

9. Subjective and
Objective exams.
PLAN including education
o Plan:
ion treatments
-up